Category: Public Health

The Children’s Health Insurance Program (CHIP), Title XXI of the Social Security Act, was initially passed in 1997 as part of the Budget Balance Act. The program’s main goal is to provide health insurance for uninsured, low-income children in households which make too much to qualify for Medicaid. CHIP has been extended in 2 and 6 year increments throughout the past two decades, and is currently set to expire in 2027. CHIP’s funding requires periodical reappropriation by Congress because legislation has not passed to fund it indefinitely. According to a report by Georgetown University Health Policy Institute, CHIP provides health coverage to 6.8 million people each month, mostly children. For the past decades, the CHIP program along with Medicaid have helped reduce the number of uninsured children by more than 60%.

About CHIP

CHIP is administered by states and jointly funded by the federal government. Each state receives an enhanced federal match for CHIP which is about 15% more than the federal match for Medicaid funding. 

States can design the program based on one of the following program designs: separate CHIP, Medicaid expansion CHIP, or combination CHIP. States with separate CHIP programs can choose among four benefit options: benchmark coverage, benchmark-equivalent coverage, the benefit package used by Florida, New York, and Pennsylvania before the enactment of SCHIP, and secretary-approved coverage. Forty-four states expanded Medicaid/CHIP up to 200% of the federal poverty line or above, and 12 of those states expanded eligibility to at least 300% of the federal poverty line. Besides uninsured children, states have the option to provide coverage for pregnant women through the CHIP program at various stages of pregnancy. States are required to cover dental coverage for children enrolled in the program. States with the Medicaid expansion programs are required to provide the full Medicaid benefit package, including EPS-DT (Early and Periodic Screening, Diagnostic, and Treatment). 

Strengths of the Program

• Receives bipartisan support and support from the public
• Increases coverage gain for children and access to children’s healthcare around the US, especially for children from near-poor family
• Improves the utilization of primary and preventive care as well as the health status of applicants after the enrollment in the program
• Incorporates a core set of quality child health measurement standards, monitoring capabilities, and reporting requirements for states
• Affords states flexibility with respect to implementation as well as encourages new developments in healthcare management for children. 

Weaknesses of the Program

• Federal CHIP funding is capped and not permanent. This financial uncertainty prevents states from making improvements.
• Limits access to children’s hospitals and certain subspecialists due to network restrictions following the enactment of ACA
• Lower retention rates and enrollments rates than expected due to lack of outreach and uncertain funding possibility
• Children are left uninsured for a period of time due to waiting periods and lock-outs in some states.
• Higher cost-sharing requirements and high charges of premiums by separate CHIP programs can diminish access to healthcare.

The Government has the power to regulate and empower how colleges can respond to the college mental health crisis through funding for mental health resources, conducting surveys on mental health, and creating a national commission to study mental health on college campuses.

The college mental health crisis is happening for numerous reasons, but the Covid-19 pandemic exacerbated existing issues. Since the pandemic, college mental health resources have been stretched thin, resulting in longer wait times and less availability to meet with mental health professionals. This has resulted in increased deaths by suicide on college campuses.

Some argue that the government must hold these colleges and universities accountable for the college mental health crisis. One main reason in favor of this position is that untreated mental health issues at college-age can affect people throughout their entire lifetimes. Given the significance of the 18-23 age range in intellectual development, it might make sense for the government to become involved in this college mental health crisis. In addition, students with mental health disabilities are protected by national civil rights laws, so the government has a responsibility to advocate for these students. One option would be for the government to create a commission to study this issue, as little research has been done on mental health in higher education.

Four main pieces of legislation tackle the college mental health crisis, ranging from the state to the federal level, including from the White House.

1. Higher Education Mental Health Act of 2021: This legislation would require the Department of Education to create an Advisory Commission for supporting college students with mental health disabilities. The commission would report on the quality and efficacy of mental health resources for college students with mental health disabilities, the impact of policies (reasonable accommodation and disciplinary policies) that either help or hurt the goal of equal opportunity for these college students, the use of protected health information of college students by their institutions of higher education, the impact of providing these resources on a student’s level of success in college (academic, well-being, and completion status), conclusions on the major challenges facing these students, and recommendations to fix this issue/improve the outcomes for these students.

Strengths: This piece of legislation is comprehensive and tackles many aspects of the college mental health crisis. Even less-talked-about parts of a college student’s mental health, such as accommodation and discipline, are taken into account in this legislation, which can impact a student’s chance of success in college. For example, if a college student is in a class where the professor penalizes absences, a student going through documented mental health issues that require them to miss class won’t be able to succeed. Similarly, if a college student is disciplined for a mental health crisis, such as for showing up to a class intoxicated continually, that student won’t receive the help they need for a possible alcohol abuse disorder diagnosis.

Weaknesses: By focusing on students with documented mental health disabilities, this piece of legislation doesn’t account for someone going through their first mental health issue or crisis that may not be documented by a mental health professional. Those without a documented mental health condition are left out of this piece of legislation.

2. Enhancing Mental Health and Suicide Prevention Through Campus Planning Act: Representative Susan Wild introduced this bipartisan legislation with Representative Fred Keller. This legislation would amend the Higher Education Act to promote positive mental health among college students and encourage comprehensive planning on college campuses to prevent mental health crises. The legislation provides for more coordination between federal agencies and colleges to develop and implement mental health and suicide prevention plans, increasing student access to mental health resources. The Act would require the Department of Education to work alongside the Department of Health and Human Services to incentivize colleges and universities to tackle the college mental health crisis.

Strengths: This piece of legislation improves on the weakness of the Higher Education Mental Health Act of 2021 by promoting positive mental health among all students, not just those with documented mental health conditions. Additionally, this Act would increase coordination between the Department of Education and the Department of Health and Human Services, both integral departments when talking about college student mental health.

Weaknesses: While this act deals with the prevention of mental health crises, it does not discuss how to manage mental health crises that aren’t prevented. For example, a college student who does not receive the mental health care that they need may have a mental health crisis, and may require hospitalization. This example wouldn’t deal with the prevention of mental health crises but would deal with the management of active mental health crises.

3. NY Senate Bill S7659A: This statewide bill would require SUNY (The State University of New York) and CUNY (City University of New York) to adopt specific provisions concerning college student mental health such as administering mental health climate surveys, establishing a mental health committee, providing mental health training to faculty and staff, and improving college policies in general regarding mental health.

Strengths: Something unique to this bill is that it would provide mental health training to faculty and staff, while other pieces of legislation focus on the hiring of mental health professionals. This is effective because faculty and staff are at the forefront of the fight against mental health crises on college campuses, and they can refer students to mental health resources before a crisis occurs. When other bills focus on mental health professionals but do not take into account faculty and staff, such as Professors and Resident Assistants (RA’s), the focus goes to the management of mental health crises rather than preventing them, and both are important.

Weaknesses: At the same time, this bill does not discuss the funding of mental health professionals. On the opposite side of the strength of training faculty and staff for the prevention of mental health crises, by not putting that same amount of resources into mental health professionals, this bill ignores the management of active mental health crises.

4. Higher Education Emergency Relief Funds (HEERF): HEERF can be used to invest in evidence-based mental health supports for students and connect the campus community to providers and care (White House/Executive Branch Legislation).

Strengths: Not all mental health supports are created equal, and by focusing on evidence-based mental health supports, this piece of legislation is strong.

Weaknesses: This piece of legislation is vague and does not define what these evidence-based mental health supports are nor does it explain how it would connect the campus community to providers and care. Additionally, many college students complain that they are always referred to community mental health professionals by the campus mental health services, which aren’t always accessible to low-income students. It might be more effective to fund and train more mental health professionals on-campus rather than refer students off-campus.

There are arguments against the government regulating colleges’ responses to the mental health crisis, including that this would be expensive in a time with high inflation and an at-risk economy. Additionally, it would be time-intensive, and there is a chance that it might not work. Some might argue that it’s not the government’s job, and either to leave it up to the colleges to decide how best to serve their students or leave it up to the students, as they will be on their own to seek mental health resources once they graduate from college. From the colleges’ perspectives, a federal commission could also hurt the colleges’ public perception, possibly dissuading parents from letting their children attend a college where so many students suffer from mental health conditions and don’t receive adequate support. Or, in other words, it would open up the colleges to talk about an issue that would put them in a negative light and hurt their business model.

Future developments in this issue include a federal commission to study mental health concerns on college campuses and periodic campus climate surveys on the mental health of college students. 

The key question here is should the federal and state governments get involved in the regulation of colleges’ responses to the college mental health crisis, a crisis that is worsened by the Covid-19 pandemic and comes at a pivotal age of development (young adulthood)? Or, do the colleges know best how to serve their students and an investment by the government would be a waste of federal and/or state resources? 

Overview

The year before the coronavirus (COVID-19) pandemic hit, the Global Health Security Index ranked the United States first in pandemic preparedness. However, 1.01 million American deaths later, it is crucial to reflect upon the actions of other countries in considering what could have gone differently in the United States. This brief will compare how the United States implemented medical leave policies, addressed hospital capacity issues, and dealt with medical supply/device shortages during the course of the pandemic, with the approaches of other countries. 

Medical Supply and Device Shortage

When an outbreak of a novel pathogen occurs, the United States federal government utilizes two tools to ensure states have the needed medical supplies and equipment: 

• The Strategic National Stockpile, which keeps medical supplies, equipment, medicines, and devices on hand to distribute amongst states during public health emergencies
• Invoke the Defense Production Act, which encourages and obliges private companies to mass produce any products that are in high demand. 

During the first two months of the pandemic, the Trump administration did not use these resources immediately, and opted to pass responsibility for medical supplies on to states. Competition for medical supplies in global markets became intense, and the Federal Emergency Management Agency (FEMA) started confiscating the personal protective equipment (PPE) that states had ordered. The prices of N95 and surgical masks soared because of global export restrictions. Furthermore, the Strategic National Stockpile was not fully equipped after being depleted by the 2009 H1N1 influenza pandemic. By March, the Defense Production Act was put into effect, two months after the first case of COVID-19 was discovered in the United States. 

The Coronavirus Aid, Relief, and Economic Security Act (CARES Act), passed in March 2020, took several steps in an attempt to address the issues with the Strategic National Stockpile and supply/device shortages, including: 

• Amending the Public Health Service Act so the stockpile was required to include PPE, ancillary medical supplies, and supplies needed for drug administration, vaccines, other biological products, medical devices, and diagnostic tests
• Raising reporting requirements for manufacturers to prevent drug shortages 
• Having the Secretary of Health and Human Services develop a publicly available and updated list of medical devices in shortage
• Having the Secretary of Health and Human Services and the National Academies of Sciences, Engineering, and Medicine work jointly to analyze the impacts of increasing domestic production and the levels of international dependence within the United States’s medical supply product chain

In December 2020, an additional $3 billion dollars was allocated to improving the Strategic National Stockpile by The Coronavirus Response and Relief Supplemental Appropriations Act. 

The Biden administration passed the American Rescue Plan, which invested $30 billion into the Disaster Relief Fund to purchase medical supplies/PPE and provided reimbursement to states, local governments, and Tribes for critical emergency response resources (such as the deployment of the National Guard). Another $10 billion was set aside for the expansion of domestic manufacturing of pandemic supplies. 

France reacted similarly in delegating the storage of PPE to individual healthcare facilities and self-employed physicians, and this strategy also caused chaos, but for different reasons. Overall, France faced difficulty when passing responsibility down from the national Ministry of Health to Regional Health Agencies (ARS) and local healthcare institutions. Due to mixed messaging from the government regarding mask necessity, masks were not readily available to the general population until July 2020. Contrary to the United States, France prioritized reducing mask stocks after the H1N1 pandemic hit, as they were criticized for their abundance of mask supply because it was seen as an overreaction to the severity of the outbreak. By early 2020, approximately 600 million masks were supposed to be destroyed and replaced per the French Public Health Agency and the Ministry of Health’s recommendation, as many of the stocks were found to be expired (but not ALL of them were expired). This inadvertently affected healthcare workers outside of hospitals the most, and it was weeks before they had an adequate supply of masks. 

Hospital Capacity

The United States did not have enough ICU and acute care beds to meet the demands of the pandemic. Even after the cancellation of elective procedures, in January 2021,  ⅕ of hospitals were still at 95% capacity in the Intensive Care Unit (ICU). Makeshift acute care units were set up in other hospital wards and spaces including lobbies and parking lots. Healthcare professionals were in high demand, and affluent hospitals retained more employees because they had the resources to pay them more, leaving rural and under-resourced hospitals short-handed. In response to such issues, the CARES act secured a portion of $150 billion for increased hospital capacity, and expanded telehealth services. The Coronavirus Response and Relief Supplemental Appropriations Act allocated funds to increase support for healthcare providers. 

Canada’s federal government compiled a list of suggested actions for regional and local healthcare authorities. Recommendations included training medical personnel in other departments to work in ICUs so that all ventilators and beds could be adequately monitored, and advance planning for transporting patients to other facilities in the event of hospitals reaching their maximum capacity. They too rescheduled non-urgent surgeries, relied on telehealth services, and decreased emergency visits by half through establishing off-site screening facilities. The early implementation of this plan contributed to Canada’s lower hospitalization and death rates than in the United States or the European Union during the first wave of the pandemic from January to April 2020. 

Medical Leave

The Families First Coronavirus Response Act (FFCRA) was passed by Congress in March 2020 and stayed in effect until December 2020. It guaranteed that:

• Full-time employees would receive up to two weeks of paid medical leave at their full salary rate if they were unable to work due to being quarantined and/or were symptomatic and getting tested for coronavirus 
• Full-time employees would receive up to two weeks of paid medical leave at ⅔ of their full salary rate if they had to care for someone quarantining or a child under the age of 18 that could not attend school or daycare due to closures attributed to COVID-19
  • Applicable to public employers and private employers with fewer than 500 employees
  • Excluded federal employees from the expanded family and medical leave provisions but left the paid sick leave provision covered under Title II of the Family and Medical Leave Act
  • Part-time employees would be covered for the average number of hours they work over a two-week period
  • Under the same provisions listed for childcare, employees could receive up to an additional ten weeks of paid leave at the same rate so long as they have been employed for 30 calendar days
    • Employers with less than 50 employees could qualify for exemption from these provisions if compliance would put their business at stake

The American Rescue Plan extended some of the benefits of the FFCRA until September 2021. This bill:

• Renewed the paid medical leave requirements and removed the exemptions for private employers with more than 500 employees and less than 50 employees
  • Made 106 million more workers eligible for paid medical leave
• Allowed employees to receive up to an additional twelve weeks of paid leave versus 10 weeks, under the same provisions listed for childcare, employees could 
• Gave all federal employees the same benefits as other full-time employees
• Guaranteed that eligible workers earning up to $73,000 annually would receive a maximum paid-leave benefit of $1,400 per week
• Provided employers with less than 500 employees the right to use refundable tax credit in order to be reimbursed for covering medical leave
• Paid medical leave reimbursement costs for state and local governments 

Germany used paid medical leave to incentivize its population to get vaccinated (a higher percentage of Germans are vaccinated than Americans). The most recent policies for paid medical leave are as follows:

• In order to qualify for up to six weeks of paid medical leave (employers are reimbursed for these costs by state governments), you must be:
  • Fully vaccinated and boosted
  • Symptomatic 
• If you meet the above criteria and need more than six weeks of paid medical leave, once the seventh week commences, you will receive a sickness benefit that is less than your salary from your health insurer instead (as long as you can provide a sick note from your doctor)
• One could apply for up to 30 days of child sickness benefits through their health insurance that would amount to 90% of their net income (with more days allotted to single parents and families with several children) if they:
  • Can provide documentation to their health insurer that confirms their child’s school or daycare facility is closed
  • Have public health insurance or are civil servants

Obesity Overview

The World Health Organization (WHO) defines obesity as excessive fat accumulation compared to a healthy weight. Body mass index (BMI) is widely used to determine whether a person is overweight or obese. If an adult’s BMI score is 30 or higher, then he or she is classified as obese according to WHO’s definition. According to WHO statistics, the number of people who are obese has more than tripled since 1975. As of 2016, over 650 million people worldwide are facing obesity issues. 

Prevalence of Self-Reported U.S Adult Obesity Rate. (Source: Behavioral Risk Factor Surveillance System)

Obesity is a severe problem for the whole world, and especially for the United States. The latest Centers for Disease Control and Prevention (CDC) statistic shows that more than 30% of the U.S adults and 20% of the U.S children population are obese. A research study conducted by Simmonds et. al. suggested that if a kid is suffering from childhood obesity, he or she has a five times higher risk of becoming obese as an adult compared with those without childhood obesity. Their study also found that the obesity risk increases as the person gets older. Obesity has major implications for America’s health and economy.

1. Obesity-related chronic diseases. National Institute of Diabetes and Digestive and Kidney Diseases (NHI) research shows that obese people are vulnerable to certain health issues including type II diabetes, cardiovascular diseases, etc.  
2. Obesity-related economic impact. The U.S government spends $190 billion on obesity-related healthcare since 2015, and the amount of money increases year by year. The expense of obesity-related absenteeism ranges between $3.38 billion and $6.38 billion annually in the U.S. 

The Causes of Obesity

Various factors can cause excess weight gain and fat accumulation in the human body, which makes obesity a complex health issue.

• An unbalanced diet and overeating: Less than 10% of U.S children and adults meet the CDC recommended amount of daily vegetable intake. Instead, study shows that high-calorie, sugar-dense, and fat-dense foods are cheap and easy to access. These types of foods can be found in vending machines, supermarkets, restaurants, etc., and they take up a large proportion of the food market. On the other hand, families prefer to buy frozen foods and pre-packaged foods because they are affordable and easy to prepare. However, these types of foods are calorie-dense. When a person feels full from eating these types of foods, he or she eats far more calories than the healthy calorie intake level. 
• Inadequate physical activity: The CDC recommended physical activity level for health benefits for an adult is 30-minutes of moderate-intensity aerobic activity five days a week (150 minutes in total) and at least two days per week for muscle-involved activities. However, according to the CDC physical activity level report from 2001 to 2005, less than 50% of U.S adults met the basic recommended physical activity level. The percentage of U.S adults who meet the basic physical activity level of CDC recommendation dramatically decreases year by year. The latest CDC physical activity level report shows that only one-quarter of U.S adults meet physical activity guidelines.
• Social determinants of health (SDOH): Over 50% of U.S households are unable to access the park within their community or need to travel more than half a mile to the park. In addition, 40% of U.S households do not have access to full-service grocery stores within their community. People who live in such SDOHs may have a hard time making healthy food choices, which increases their risk of becoming obese. 

Sugar-Sweetened Beverage (SSB) and Consumption

Sugar-sweetened beverages (SSB) are the main sources of added sugar in U.S household diets, which are large contributors to the obesity rate. The CDC defines SSB as “any liquids that are sweetened with various forms of added sugars like brown sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, high-fructose corn syrup, honey, lactose, malt syrup, maltose, molasses, raw sugar, and sucrose.” According to the National Health Interview Survey Cancer Control Supplement (NHIS CCS), from 2010 to 2015, about six in ten U.S adults drank SSB one or more times per day. Although the prevalence of SSB intake differs in states, the consumption of SSB ranges from 44.5% to 76.4%.

Sugar-Sweetened Drink Taxes Policy

A Sugar-Sweetened Drink Tax (SSDT) represents one policy strategy to reduce sugar consumption in communities. The tax targets suppliers that produce beverages (such as sports drinks, fruit drinks, tea, etc.) with added sugar (“a total sugar content of five grams or more per 100 milliliters”) and sell their products across state lines. Because SSDTs have only been introduced recently, this policy has not been widely implemented in the U.S. Several cities have levied SSDTs locally including Boulder, Navajo Nation, Cook County, Philadelphia, Seattle, Berkeley, Albany, Oakland, and San Francisco. In addition, SSDTs have been adopted by over forty other countries. 

Cities Implemented SSDT Across the U.S. (Source: Healthy Food America)

SSDTs effectively reduce sugar consumption by increasing the price and reducing the sale of SSBs. The rate of SSDT varies among cities. For example, the SSDT for cities in California is 1 cents per ounce, and it is 2 cents per ounce in Boulder. Such taxes on SSB products result in a 43% to 120%  price increase for consumers. The volume of SSB sales in cities that adopted SSDT decreased by 21 to 39 percent. 

Challenges 

Some critics have argued that SSDT was implemented prematurely, and inadequate data and poor policy design make it difficult to determine if the policies are actually effective. Further, some unintended consequences have been observed after implementing SSDT.

1. SSDTs tend to be regressive taxes because low-income families spend a larger proportion of their income on groceries compared to high-income families. As a result, SSDTs have a disproportionate impact on lower-income households. 
2. SSDT does not directly reduce the amount of sugar in drinks, and it does not necessarily reduce sugar consumption. Based on SSDT content, all per-unit SSDT is calculated using the volume of qualifying beverage rather than the sugar content. In other words, the tax for an eight-ounce iced tea (which contains two teaspoons of sugar) is equal to the tax rate for an eight-ounce soda (which contains seven teaspoons of sugar). 

Benefits of SSDT

Currently, cities that implemented SSDT are spending SSDT revenue ($135 million per year) to address their specific healthcare needs and improve low-income community health. These cities focus on increasing public awareness of healthy beverages and diabetes through social media and education campaigns. Specifically, Albany, CA, spends SSDT revenue for local healthcare and youth nutrition education. Boulder, CO, reaches out to local restaurants, markets, and drink producers to reduce misinformation regarding SSB. Seattle, WA, boosts access to nutritious food and water and educates people about nutrition and healthy beverage options. SDOH, including parks, leisure facilities, and sports fields, are addressed. In addition, SSDT revenue is also used to enhance the obesity-related healthcare system.